Understanding Little League Elbow: Causes, Risks and Prevention

As sports specialization and year-round play among younger athletes in baseball have become increasingly prevalent, so has the prevalence of Little League elbow. Although these trends seem likely to persist, there are preventive measures athletes can take to reduce their risk of injury – especially for throwers in colder weather. Clinicians can also take more steps and prioritize specific aspects of the diagnosis, treatment and recovery process to help athletes return to play quickly and, most importantly, safely.

“‘Little League elbow’ is a term that I’m not really a fan of,” says Paul Saluan, MD, Director for Pediatric and Adolescent Sports Medicine at Cleveland Clinic. “It’s really an umbrella term that isn’t specific to what the injury is. It’s just a term that signifies a constellation of elbow pain in a young thrower. As sport medicine specialists, we can identify where the pain is coming from and develop a more direct diagnosis than having to use an umbrella term. I typically refer to them as ‘overuse-related elbow injuries.’”

Understanding the injuries

Dr. Saluan notes that the typical Little League elbow patient is generally a younger thrower with open growth plates. An open growth plate is susceptible to stress and injury from repetitive throwing motions and overuse.

“When I’m diagnosing a patient, location is everything,” he explains. “During the throw, each part of the elbow transfers force differently across the throwing motion—often at high speeds.”

As the thrower comes up in the motion, they’re opening up the medial aspect of the elbow under tension. Then, the force is transferred as they continue through and compresses the lateral side of the elbow. On the follow-through, the posterior side experiences shear force.

“With all these different parts of the elbow being stressed just across a single throwing motion, it’s easy to see how overuse can lead to injury — especially at this vulnerable period of development when the growth plates are still open,” says Dr. Saluan. “While all of these different types of forces cause different injuries to the elbow and require different treatments, all of these injuries still fall under that ‘Little League elbow’ umbrella term.”

Injury treatment and management

Because overuse-related elbow injuries encompass several types of injuries, it’s important to define what exactly the injury is to direct the treatment approach.

When a young thrower presents with an elbow injury, Dr. Saluan says the first step is to get an X-ray. “The X-ray helps us establish a baseline,” he explains. “We look at the growth plates on both the inside and outside of the elbow, and between the X-ray and the patient’s reporting and history, we can get a pretty good idea of what’s going on.”

As part of the patient history, Dr. Saluan typically asks how long the pain has been present as well as where in the throwing motion is most painful. “The entire diagnostic process is quite similar to how we would diagnose an older throwing patient; we just come to different conclusions because of the open growth plates.”

With treatment for any type of elbow injury, rest and avoiding throwing are critical. With younger throwers, physical therapy can be especially helpful. Working with a physical therapist can help the patient strengthen their core, and some physical therapists can also help them visualize the entire kinetic chain involved with throwing to help them make tweaks in their motion, so their injuries don’t become recurrent.

“In terms of return to play, we recommend that patients are pain-free, have a full range of motion and have full strength,” says Dr. Saluan. “Even after hitting those benchmarks, it should still be a gradual return to play program in which the thrower slowly ramps up their activity. If at any point, they experience discomfort, it’s important to back things up in the process and slow down.”

Impact of cold weather

Although lower temperatures don’t directly cause an elbow injury, they can exacerbate symptoms. In cold weather, vasoconstriction reduces blood flow to the extremities, muscles and tendons. The reduced circulation limits the delivery of oxygen and nutrients essential for optimal muscle and tendon function, which can lead to increased stiffness and reduced elasticity.

“Proper warm-up in cold weather is essential,” explains Dr. Saluan. “Before pitching, a young thrower might need to spend extra time focusing on dynamic stretches that will help increase blood flow to the muscles and joints. It’s also important to remember that the thrower isn’t just warming up their elbow, but they need to make sure the whole kinetic chain is warmed up — the shoulder needs to be warm too. In colder weather, the shoulder won’t quite have the same range of motion as it would in warmer weather. If the shoulder isn’t warmed up enough, the thrower is likely going to put undue stress on the elbow.”

Injury prevention

While cold weather can aggravate an elbow injury, the primary cause of Little League elbow is typically from overuse.

“As sport specialization has become more prevalent, we’re seeing an increase in younger patients presenting with elbow pain from overuse,” says Dr. Saluan. “Some of these throwing athletes are pitching year-round, and they’re not taking time to rest and heal. If they’re throwing every single week of the year, they’re going to create attritional injuries. They’re also going to develop failure points based on the chronic torsional load they’re repeatedly putting their arm through. It often seems like kids don’t play anymore – they train.”

Dr. Saluan says that coaches can play a major role in elbow overuse injury prevention. Beyond warmups, emphasizing proper techniques and efficient throwing mechanics at a young age can help ensure that a thrower isn’t placing too much stress on a certain part of the elbow. Limiting throwing volume and ensuring rest can also help the body recover between throwing sessions. Encouraging a thrower to communicate any signs of pain early can also help prevent minor injuries from becoming major ones.

“We typically see most of these elbow overuse injuries at around 12 to 13 years,” says Dr. Saluan. “These throwers are beginning to jump to the higher levels of the sport, they’re trying to impress their coaches, they’re throwing all day, and they're starting to play around with different pitch types. It’s our job as providers, coaches and parents to press the brake pedal when we need to. It can be difficult because we want our kids to be active and passionate, but we also want to put them in a position where they can succeed. But letting a 12-year-old pitch every week of the year without giving them time to heal and recover is only going to set them up for injury.”